President Obama’s proposal of August 2013 to tie individual students’ financial aid to government ratings of the college they attend is perhaps the worst idea ever put forward for higher education by a sitting president. Two of the major proposed metrics — graduation rates and post-graduation employment and income — are inexorably bound up with the nature of the students that the colleges serve. Poverty, poor preparation, commuter and part-time attendance, and non-traditional adult age status are all highly correlated with lower completion rates.
Add the third major Obama proposed metric — affordability — and the administration has put an admirable set of non-profit educational institutions in the crosshairs. By history, mission and commitment, they serve student bodies disproportionately drawn from disadvantaged, underserved populations. These institutions, most of them animated by deep religious or social activist traditions, are neither as inexpensive as public institutions nor as successful by conventional measures as wealthy, selective, private institutions that by and large serve the children of the upper reaches of the social order.
If the Obama administration has its way, many good colleges could be marked for extinction, or driven to subvert their ideals by jettisoning at-risk students to lower their own risk of failing the ratings test.
This is not an abstract possibility. There is a telling historical precedent for the consequences of applying a well-intended rating system to a heterogeneous collection of institutions of higher education, with devastating consequences for those serving marginalized populations. In 1900, the United States had about 160 medical schools of extraordinarily variable quality, ranging from small storefront diploma mills to research institutions like Harvard and Johns Hopkins. There was also a developing consensus that medical education needed to better reflect the scientific revolution in medicine of the preceding century and to offer deeper clinical experience. A reform movement developed with the admirable aims of professionalizing medical education based on scientific research and tying teaching directly to hospital practice.
This movement succeeded. The quality of physicians improved immensely as a result — but in the process it cut the number of American medical schools in half and almost destroyed medical education for African Americans and women. By 1923, eight of the 10 Black medical schools that existed in 1900 were out of business. Only Howard and Meharry survived the purge, and then only barely and by special dispensation. Women’s medical schools did not fare any better. By 1930 six of the seven early 20th century women’s medical schools were extinct. Opportunities for medical education for African Americans and women were severely curtailed and did not recover until the social movements of the 1960s and 1970s forced fairer, more enlightened admissions policies.
Before this drastic change, the profession of medicine was accessible to motivated working-class individuals. After their implementation, it became a bastion of upper-middle-class White males and remained so for decades after. In addition to curtailing individual opportunity, this led to a major loss of physicians serving urban minority communities and rural areas, problems that still afflict American medicine.
A major catalyst for this social catastrophe was a rating system not so different from that proposed by the Obama administration. In 1907 the reform-minded Committee on Medical Education (CME) of the American Medical Association (AMA) developed a rating system to grade each existing medical school as “A” (acceptable), “B” (needing improvements but redeemable), or “C” (in need of complete reorganization). Criteria for good ratings included enforcement of entrance requirements, a coherent curriculum, and adequate library facilities.
However getting an A rating, the only rating that in the end guaranteed long-term survival, also required an adequate financial endowment, acceptable clinical teaching facilities, and a core full-time science faculty with an active research program. Even some good, practically oriented medical schools failed to make an A rating based on these criteria and eventually succumbed, Fordham and Bowdoin among them. But the system was especially powerfully stacked against Black medical schools, women’s medical schools and schools serving a working-class student body. These intuitions were eventually devastated.
Shortly following the development of the CME rating system, the Carnegie Foundation enlisted Abraham Flexner, a committed progressive school reformer with a background in high school education, to prepare a report on the adequacy of American medical education. His 1910 Carnegie publication, commonly referred to as the Flexner Report, galvanized the medical education reform movement. He visited every existing medical school in the United States and Canada, and provided a hard-eyed view of the strengths and shortcomings of each. His gripping conclusion was that a majority of schools were doing more harm than good and deserved to close.
However, neither Flexner nor the CME could close underperforming medical schools. State licensing agencies held that power through their ability to grant or deny licenses to practice. Flexner’s muckraking report led to tremendous public pressure on these hitherto sleepy and in some cases corrupt boards to take action. After 1910 they put many medical schools out of business, in effect giving the ratings of the CME the force of law. By 1914, C-rated schools were denied recognition in 31 states. Then, from its inception in 1915, a new National Board of Medical Examiners, closely tied to the AMA (its primary founder, William L. Rodman, was simultaneously the president of the AMA), examined only graduates of A-rated schools. Over time, as state boards adopted its standards, non-A-rated schools were forced out of existence. Between 1904 and 1920 the number of US medical schools dropped from about 160 to 85 and enrollment fell 51 percent.
Despite some patronizing views regarding the role of African Americans in medicine, Flexner supported medical education for Blacks, and recommended that Howard and Meharry be saved. This was accomplished in part through a specially created CME rating category for “Medical Schools for the Colored Race” that gave Howard and Meharry A ratings in 1910, though Meharry slipped back to a B rating in 1914 and just barely managed to re-achieve an A rating in 1922. (Interestingly, White southern schools also got special leniency in the ratings, though not a special category, as a concession to the backwardness of the southern educational systems of the day.)
In the end, Howard and Meharry were saved, though not without some close calls and with shockingly little help from the philanthropists who backed the general medical education reform movement. To give some measure of the importance of their survival, in 1950 there were 653 Blacks enrolled in US medical schools. About 500 of them attended Howard and Meharry, which were together graduating about 100 physicians annually. Nationwide, all other medical schools combined graduated only 10 to 20 Blacks annually. Despite the significant victory entailed in their salvation, the overall setback to equality of opportunity and access in medical education was profound, and offers a cautionary lesson for present-day policy debates.
Several of the issues that engaged the medical education reformers intersect directly with today’s debates around the reform of higher education to improve graduation rates and outcomes. For example, Flexner and the CME made a major target of proprietary medical schools, for-profit businesses that typically offered little or no clinical experience and in many cases were little more than diploma mills. Flexner excoriated them as self-interested exploiters deserving of contempt. Both the CME and Flexner pressed hard to close all proprietary schools and by 1930 they were all defunct. Today, concerns about the proprietary sector in higher education are clearly a major factor motivating the president’s rating proposal.
The reformers’ animus toward proprietary schools extended to all medical schools that served working-class students through part-time and evening courses. For example, in 1907, shortly after the advent of the rating system, the AMA House of Delegates instructed the CME not to give any school offering evening courses a rating higher than C, arbitrarily condemning schools that served working students with day jobs. Howard had to abandon night classes to stay in good graces.
There are echoes of this attitude in the emphasis that the Obama administration seems to be placing on “undermatching,” the supposed paucity of well-prepared students from disadvantaged backgrounds who enroll in high-quality institutions, with quality implicitly defined in terms of elite, residential colleges serving traditionally aged students. This approach concentrates on sending a relatively few students to “good” schools. It neglects the larger and more important task of providing viable local opportunities for the majority of disadvantaged students, most of whom — by circumstance — must attend non-residential colleges that permit them to combine study, work and care for their families.
On another front, the reformers of the early 1900s were concerned about low entrance standards, finances inordinately dependent on tuition, and low performance outcomes as measured on state licensing exams. Today’s higher education reformers are concerned in parallel about poor preparation of students, finances inordinately dependent on student loans and low performance outcomes as measured by graduation rates. The danger is that, as in the Flexner–CME episode, the remedy proposed to cure these ills will inadvertently disadvantage or even eradicate the very institutions that have done the most over the years to serve marginalized populations historically excluded from higher education.
The medical education reformers did not target black medical schools. In fact, the AMA barely acknowledged that they existed as a category and Flexner wanted to save Howard and Meharry, despite their shortcomings. But, the poverty of African American medical students, the lack of wealthy alumni, and a paucity of philanthropic funding guaranteed that the black medical schools were starved for the kinds of resources they needed to raise their educational standards to acceptable levels. Sound familiar?
Today, most colleges that serve students from disadvantaged backgrounds struggle to do so in the face of modest tuition income, poor student preparation, and little or no access to the kinds of major alumni and philanthropic donations that could make the task easier. The depth of the challenge is reflected in the relatively low retention and graduation rates of the schools that serve this population.
The president now proposes to exacerbate these challenges by giving those students who choose to attend low-rated colleges even less loan and grant money. This, combined with the push for “affordability,” a goal that was distinctly absent in the medical education reform movement, will have the effect of directing the vast majority of economically disadvantaged students to already overstretched and under-resourced public institutions, particularly community colleges.
This approach will further undermine the economic position of independent four-year colleges that have chosen to serve these populations, including a large majority of Historically Black Colleges and Universities. Public institutions will always have the advantage of low cost to compensate in the ratings for any shortcomings in graduation rates or other outcome measures.
It is highly unlikely, on the other hand, that a single mitigating rating criterion, such as the proportion of a college’s students on Pell Grants, as proposed by the president, will overcome the double disadvantage of outcomes driven in part by disadvantage and the practical necessity to bring in enough tuition revenue to cover the cost of education. The whole rating proposal puts independent, non-profit colleges serving disadvantaged students at serious risk.
There is an alternative approach that deserves consideration. If we wish to preserve access and opportunity for the disadvantaged as a hard-won hallmark of our educational system and achieve higher levels of retention, graduation and mastery, we should devise a system that channels more, not less, aid to the students who need help the most and to the institutions that serve them.
If philanthropic funders had had the will, medical education reform in the early 20th century could have been coupled with targeted support to African American and women’s medical colleges to help them surmount the challenges of achieving adequate standards. Had this happened, thousands more African American and women physicians would have practiced during the 20th century, to the great benefit of all.
To avoid the same mistake, we should commit to reform in higher education that is supportive — not punitive — of institutions historically dedicated to the cause of access and opportunity. If we do not, and take the opposite course, we may inadvertently put a lot of them out of business, and in the end restrict rather than enhance opportunity for disadvantaged students.
Dr. Vinton Thompson is president of Metropolitan College of New York.
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